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Patient Safety Learning

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  1. Patient Safety Learning
    Labour is unlikely to meet its key election pledge on tackling NHS waiting lists, analysis has suggested.
    Sir Keir Starmer was elected after promising that 92% of routine operations and appointments would be carried out within 18 weeks by 2029.
    However, a major report by the Health Foundation think tank said that, at the current rate of progress, Labour would “fall short of delivering on its headline pledge”.
    The overall hospital waiting list stands at 7.4 million, down from 7.6 million when Labour took office. But it has risen for the past two months, and currently only 61 per cent of patients are seen within the 18-week target.
    The report said that based on current trends, the overall waiting list will be 4.7 million at the time of the next general election in four years’ time. This would be the lowest figure since 2021, but not low enough to meet the election pledge.
    It also warned that further disruption, such as another wave of junior doctors strikes, could make it even harder to lower waiting lists.
    Dr Francesca Cavallaro, a senior analytical manager at the Health Foundation, said: “The scale of the challenge remains significant, and even getting close to meeting the target would be a considerable achievement. This will require not just more activity, but smarter use of resources and continued investment in the NHS workforce and infrastructure. And there are several factors that could hold back progress, including if future referrals rise faster than expected and the potential impact of further industrial action."
    Read full story (paywalled)
    Source: The Times, 25 September 2025
  2. Patient Safety Learning
    Yorkshire has recorded one of the sharpest drops in childhood vaccination rates in England, with uptake in Bradford among the worst nationally.
    NHS data shows the proportion of two year olds in the region who have received their first dose of the vaccine fell from 92.8% in 2018-19 to 90.1% in 2023-24.
    Health authorities warn that coverage needs to reach 95% to prevent outbreaks of the viruses.
    Andrew Taylor, interim director of public health at Bradford Council, said the authority was working hard to address the issue, adding that misinformation was partly to blame.
    "We really do want to improve the rates of immunisation," he said.
    "It is disappointing to see that we're lower in this latest period than we really wanted, because we're putting in a lot of work to encourage people."
    He said there was a growing feeling of reticence around vaccinations, saying people were becoming "more hesitant than they used to" and criticised those in the public eye who cast doubt on vaccine safety.
    "Any politician, as far as I'm concerned, who promotes ideas that vaccinations don't work is actually putting the public at risk and should think very carefully before they spread that [message]."
    Read full story
    Source: BBC News, 26 September 2025
  3. Patient Safety Learning
    The World Health Organization (WHO) is pushing back against contested claims by the Trump administration that acetaminophen use during pregnancy heightens the risk of autism, further underscoring that no scientific consensus supports such a connection.
    “Extensive research, including large-scale studies over the past decade, has found no consistent association,” the agency said in a Wednesday statement.
    “[The] WHO recommends that all women continue to follow advice of their doctors or health workers, who can help assess individual circumstances and recommend necessary medicines.”
    The concern had escalated earlier in the week when Donald Trump, alongside senior health officials including Robert F Kennedy Jr, issued a warning about acetaminophen, the active ingredient in Tylenol, alleging it contributes to rising autism rates. The announcement also included plans for a new study examining potential links between childhood vaccines and autism.
    “Taking Tylenol is not good … all pregnant women should talk to their doctors about limiting the use of this medication while pregnant,” Trump said on Monday.
    WHO stressed that all medications should be used with caution during pregnancy, especially in the early stages, but pointed out that previous studies raising alarms about acetaminophen were flawed and have since been discredited.
    The organization also reaffirmed its stance on vaccines and said that “large, high-quality studies from many countries have all reached the same conclusion” – that vaccines do not cause autism. It emphasized that over the past five decades, global immunization efforts guided by the agency have prevented at least 154 million deaths.
    The vaccine schedule “remains essential for the health and wellbeing of every child and every community”, it said.
    Read full story
    Source: The Guardian, 24 September 2025
  4. Patient Safety Learning
    Thousands of children are facing long waits for vital wheelchairs as NHS rejections rise, and the UK’s only charity has been forced to stop taking new patients due to a surge in demand.
    Whizz Kids, the UK’s leading charity for specialist wheelchair services, has warned patients are facing a “national crisis” after unprecedented pressure on its services has forced it to close to new referrals for the first time in over three decades.
    The charity’s leaders said demand has risen 12.5% year on year because more children are being rejected by the NHS for specialist wheelchairs, which cost on average £4,800, due to cost concerns.
    One of those children, Charlie Drinkwater, who has spina bifida and growth hormone deficiency, has been denied a specialist chair by the NHS for the past five years.
    Although she is eight years old, she is the size of a two-year-old, and so she needs a specialist chair, which could cost up to £4,500. However, due to budget constraints, the NHS does not provide chairs for under-five-year-olds, according to Whizz Kids. The NHS would only offer her a buggy, despite being eight years old.
    Now, having grown out of the first chair provided by the charity, and having again been rejected by the NHS, Charlie’s childhood is on hold while she waits for a new one.
    She told The Independent: “I’m excited for my new chair because it’s going to be pink. But it makes me sad when it takes a long time.”
    Read full story
    Source: The Independent, 25 September 2025
  5. Patient Safety Learning
    Ablue, burgundy and white patterned wrapper hides the swell of Joanna Banda’s belly. Eight months pregnant, she has had just three of the five antenatal appointments she should have had. She is unlikely to attend her final three either, as she still has to save 3,000 kwacha (£1.28) for a bicycle to take her six miles on rutted dirt tracks to the nearest health centre when she goes into labour.
    In remote villages in Malawi, pregnant women such as 22-year-old Banda, who has one child after losing her first soon after giving birth, are struggling to get the medical care they need.
    In January, US aid cuts abruptly ended a rural healthcare outreach programme that was starting to reduce the number of local women dying in childbirth.
    Momentum Tikweze Umoyo, a five-year $28m (£20m) programme aimed at cutting maternal and infant mortality rates in five of Malawi’s 28 districts, was meant to last until 2027.
    It is just one of the many casualties of Donald Trump’s decision to suspend foreign aid just hours after taking office in January, risking the lives of some of the world’s poorest, most vulnerable people. In July, Congress approved $9bn in cuts to aid and public broadcasting. Last month, the US president said he would be cancelling $4.9bn in aid already approved by Congress.
    Kafulatira, where Banda lives, was once regularly visited by a mobile clinic, but villagers now have to walk 11 miles to the nearest health centre. 
    A mobile clinic used to visit the community every month or so, providing a private space for women to get screening for cervical and other cancers, HIV tests and treatment, and vaccinations for children. It also provided antenatal checkups and family-planning services, including contraception.
    “The outreach clinics were helping a lot, because we could access services right here in the village,” Mulirani Gerard says through a translator. “Since last year, we had been waiting for the team to come, so we were just wondering what had happened.” No one told villagers why their healthcare had been cut.

    Read full story
    Source: The Guardian, 25 September 2025
  6. Patient Safety Learning
    The night a baby died with an undiagnosed heart condition in a Kent hospital was "quite chaotic", a court has been told.
    Head nurse Ronald Carrido was giving evidence at an inquest into the death of seven month-old Tommy Kneebone on 21 January, 2023, at Tunbridge Wells Hospital in Pembury, Kent.
    Mr Carrido told the inquest he called for consultant help "when there was no improvement in Tommy, when he was deteriorating".
    The boy's mother, Shanice Kneebone, previously told Kent and Medway Coroner's Court in Maidstone that "no-one took her concerns seriously" at the hospital.
    At the hearing on Wednesday, his parents also heard from the consultant on duty that night.
    Breaking down in tears, Doctor Chhaya Patankar told the inquest when she went into his room at 19:00 GMT, Tommy looked at her with "such bright, beautiful eyes".
    The paediatric consultant said she examined Tommy, listened to his heartbeat and checked his liver.
    He "responded like any baby would do," she said.
    Dr Patankar said the baby had mild respiratory distress, which "fitted with" what she had been told.
    "But there was a lack of the broader picture," she said.
    Read full story
    Source: BBC News, 24 September 2025
  7. Patient Safety Learning
    Women who miss their first breast cancer screening appointment have a 40% higher risk of dying from the disease, according to a new study.
    Experts at the Karolinska Institute in Sweden analysed data for about half a million women across Sweden, with the findings published in the British Medical Journal. The women all received their first screening invitation between 1991 and 2020 and were monitored for up to 25 years.
    After taking into account social, economic, reproductive, and health-related factors, the researchers found almost one in three (32%) women did not attend their first mammogram appointment.
    Not attending a first screening was linked with a significantly higher risk of breast cancer death – 9.9 deaths per 1,000 women over 25 years – compared with seven in those screened.
    These women were also less likely to attend subsequent screenings and were more likely to be diagnosed with advanced stage breast cancer than those who were screened.
    In contrast, the 25-year breast cancer rate was similar between groups. This suggests that the higher death risk among those not attending a first appointment reflects delayed detection rather than increased incidence of the disease, the team said.
    The researchers wrote: “First screening non-participants had a 40% higher breast cancer mortality risk than participants, persisting over 25 years.
    “If early screening behaviour is predictive of later stage diagnosis and mortality risk, it could provide a valuable opportunity to identify populations at high risk decades before adverse outcomes occur.”
    Read full story
    Source: The Guardian, 24 September 2025
  8. Patient Safety Learning
    An area with high stillbirth rates has found there were “significant” gaps in maternity care in more than one in five cases, in a newly published review.
    The review of stillbirths across the Black Country was commissioned by its local maternity and neonatal system (LMNS), following an increase in rates since 2020. 
    The review, dated March 2024, has just been published by the integrated care board, after repeated requests from HSJ  and others.
    It states that stillbirths and neonatal deaths were both continuing to increase in 2023, but “this is at a more significant rate for stillbirths”.
    More than a fifth (22.5%) of the reviews identified “significant modifiable factors” – where different management might have saved the baby’s life – and 42.5% found “minor modifiable factors”, which are issues that may have contributed but are unlikely to have changed the outcome.
    The review, carried out by a panel of senior local clinicians, sets out a wide range of shortcomings in the cases, and recommendations.
    It gives several examples where there is a failure to pursue apparent concerns and warning signs during pregnancy.
    Under issues with “risk assessment”, the report says: “There was a concern that there appeared to be a lack of professional curiosity. Particularly in relation to medical problems that occurred during the pregnancy and the discord between the plans for pregnancy care and the implications of the medical problems and their effect on the pregnancy and care.”
    Read full story (paywalled)
    Source: HSJ, 25 September 2025
  9. Patient Safety Learning
    The NHS’s first proposed skills framework for managers has too much “fuzzy language” and needs to be simplified, the NHS England board has decided.
    It is meant to give clinical and non-clinical NHS management its first “code of practice, defined set of standards and competencies [and] a national development curriculum” and to “elevate NHS management and leadership as a recognised professional discipline”.
    It should “work alongside” the government’s proposed management regulation and “any potential future accreditation [system]”, a board paper said.
    It responds to recommendations from a 2019 review of the “fit and proper person test” by Tom Kark KC, and the 2022 Messenger review of NHS leadership, as well as renewed support for management standards and accountability after Lucy Letby’s conviction for murdering babies in Chester.
    But NHSE chair Penny Dash told the NHSE board meeting that officials needed to “tighten up” the current document and its language, and include clearer methods for measuring leaders’ performance.
    She said: “I have to say I had a bit of a personal problem with some of the language in here. This one on self-effectiveness [says], ‘keep safe’.
    “What does that mean? Does that mean I walk slowly down the corridor? We keep using that word, I wouldn’t know what that meant.
    “We’ve also got things in here like ‘patient-centred care’, I don’t know what that means. We’ve got a whole lot of really good patient experience metrics, which we could be aspiring to, so we’ve got a bit too much fuzzy language in here.
    “I think we need to be much clearer on the sorts of things we have been talking about [at the board] today, like ‘do we have a group of managers who can really think about resource allocation?’
    “We do refer to that but I’m not sure it’s quite tight enough.”
    Read full story (paywalled)
    Source: HSJ, 24 September 2025
  10. Patient Safety Learning
    An NHS trust at the centre of concerns over its poor maternity services has had to repay almost £5m after wrongly claiming it provided safe care to mothers and their babies.
    Leeds Teaching Hospitals NHS Trust was paid the money after saying its services met safe standards of care and staffing.
    But a subsequent investigation by the health service's litigation arm, NHS Resolution, found the trust had not met the standards and asked for the money to be repaid to the NHS.
    The trust received the money under a programme called the Maternity Incentive Scheme, which is run by NHS Resolution to encourage the health service to provide good maternity care.
    Hospitals are asked to judge their performance against a range of standards, including listening to patients' concerns, staffing levels and properly investigating deaths.
    If a trust meets all 10 safety measures, it can get a rebate on its insurance premiums as well as a share of the money paid by trusts that do not meet all the goals.
    For the past two years, the Leeds trust reported it had met all 10 standards and was paid £4,887,084 from the scheme.
    But the regulator, the Care Quality Commission (CQC), published a damning report in June about maternity services at the trust. Care was rated as inadequate, the lowest level, and it warned that women and babies were being exposed to "significant risk".
    The report prompted NHS Resolution to ask Leeds to re-examine its submissions to the Maternity Incentive Scheme. The subsequent review found not all safety standards had been met, forcing the trust to repay all the money it had received.
    Read full story
    Source: BBC News, 24 September 2025
  11. Patient Safety Learning
    The current home-birth system in Ireland creates a “risk to patient safety”, an internal health audit has found.
    The Health Service Executive (HSE) audit reached this finding as there is no agreed maximum safe travel time to the nearest maternity unit or self-employed community midwife (SECM).
    In February 2022, the home-birth service was moved from community operations to acute operations and is now integrated into the 19 maternity services nationwide.
    In light of this, the HSE conducted an audit to establish the “adequacy and effectiveness of governance and risk management” of the home-birth service.
    The auditors examined three sites – Cork University Maternity Hospital, Rotunda Maternity Hospital and the Coombe Maternity Hospital – and reviewed 30 midwifery notes relating to home births that occurred from March 1st, 2023, until February 29th, 2024.
    It found weaknesses in the system of governance across all three sites that the audit said created a “significant risk that the system will fail to meet its objectives”.
    According to the audit report, there is “no national governance structure in place” for home births as acute operations no longer has oversight due to the reorganisation of the HSE into the six health regions.
    Read full story
    Source: Irish Times, 23 September 2025
  12. Patient Safety Learning
    Thousands of pharmacies in England will offer free NHS flu spray doses to toddlers for the first time this year.
    The vaccination is given via a child's nose and two and three-year-olds could previously access them at their GP surgery.
    Around 4,000 pharmacies have signed up to deliver the vaccine to 1.2 million eligible toddlers from 1 October.
    Both walk-in and booked flu vaccine appointments will be available as part of the NHS drive to increase vaccine uptake nationally.
    NHS England stats show that last winter, there were more than 300,000 hospital bed days taken up by patients with flu – almost double the previous winter.
    It's a situation Health Minister Ashley Dalton said "we cannot afford a repeat of" this year.
    The hope is that by vaccinating young children, they are not only protected from catching flu, but they will also not pass the virus on to others.
    Read full story
    Source: BBC News, 24 September 2025
  13. Patient Safety Learning
    Patients have complained about disruption to outpatients bookings and waiting lists following the introduction of  a new electronic patient record (EPR) system at Sheffield Teaching Hospitals NHS Foundation Trust.
    The trust went live with its £85 million Oracle Cerner EPR in July 2025, following an eight month delay to deal with “outstanding issues” around system and organisational readiness.
    Following the go live, Clive Betts, MP for Sheffield South East, wrote to Kirsten Major, chief executive of the trust, stating that constituents had “serious concerns about an ongoing failure in the hospital’s digital patient records system that has persisted for a number of weeks”.
    “According to these reports – which specifically mention cardiology and potentially other departments – the trust’s electronic system has been ‘down’ or malfunctioning in a way that waiting list data and patient records have gone missing or become inaccessible.
    “In one case a patient was informed by staff that the cardiology department no longer knows who is on their waiting list due to this system issue.
    “Understandably, this situation is causing anxiety to patients who are unsure if they remain in the queue for treatment or have ‘fallen off’ the list through no fault of their own,” the letter says.
    Responding to the concerns, Major told Digital Health News: “A change of this magnitude and scale is bound to have some initial issues to resolve and we have had disruption to some of our outpatient appointment booking processes and correspondence.
    “We picked this up very quickly and thanks to the amazing work of our staff many of the clinics affected have already been corrected, and we have a programme of work to complete the remainder as quickly as possible to limit any impact on existing waiting times.
    “Our clinical teams are continuing to triage and prioritise the most urgent appointments as normal, and all patients will be contacted as soon as their appointment is ready to be scheduled in line with the waiting time for that clinic or service.”
    Read full story
    Source: Digital Health News, 24 September 2025
    Related reading on the hub:
    EPR systems and concerns about patient safety (Patient Safety Learning)
  14. Patient Safety Learning
    Following the announcement by US President Donald Trump that US physicians will soon be advised not to prescribe paracetamol (known as Tylenol in the US) to pregnant women, Dr Alison Cave, Chief Safety Officer at the Medicines and Healthcare products Regulatory Agency (MHRA), said:
    "Patient safety is our top priority. There is no evidence that taking paracetamol during pregnancy causes autism in children.   
    "Paracetamol remains the recommended pain relief option for pregnant women when used as directed. Pregnant women should continue to follow existing NHS guidance and speak to their healthcare professional if they have questions about any medication during pregnancy. Untreated pain and fever can pose risks to the unborn baby, so it is important to manage these symptoms with the recommended treatment. 
    "Our advice on medicines in pregnancy is based on rigorous assessment of the best available scientific evidence.  Any new evidence that could affect our recommendations would be carefully evaluated by our independent scientific experts. 
    "We continuously monitor the safety of all medicines, including those used during pregnancy, through robust monitoring and surveillance. We encourage anyone to report any suspected side effects to us via the Yellow Card scheme."
    Read full press release
    Source: MHRA, 23 September 2025
    MHRA factsheet on taking paracetamol while pregnant:
    Factsheet - Paracetamol and Pregnancy.docx
  15. Patient Safety Learning
    The NHS must change how black men are treated for prostate cancer to prevent “an epidemic of unnecessary deaths” in which twice as many die as white men, campaigners have warned.
    Academics are seeking to raise awareness that one in four black men are getting this cancer, twice the rate of white men, which is one in eight, according to Prostate Cancer UK’s analysis of patient datasets for England. One in 12 black men are at risk of dying of this condition compared with one in 24 white men.
    “We are living through an epidemic of unnecessary deaths of black men,” said Stafford Scott a community activist. “Prostate cancer is not colour blind. Not only is the death rate twice as high in black men as white men but we are being diagnosed late and so are coming into the system late.”
    Scott, the director of the organisation Tottenham Rights, is teaming up with experts to launch a podcast series calling for fundamental changes in the NHS approach to prostate cancer and its high incidence among black men to prevent many more deaths.
    This would reflect Prostate Cancer UK’s call to change “outdated NHS guidelines” so that GPs can be advised to start conversations with black men earlier and discuss with them taking prostate-specific antigen (PSA) blood tests to indicate cancer.
    Approximately 55,300 new prostate cancer cases are diagnosed across the UK every year and this figure is projected to rise by 15% in the next 15 years.
    Scott suggested that prostate cancer diagnosis and treatment could also be improved through broader NHS reforms, such as improving how it recruits and promotes black staff, including into leadership positions; partnering with black-led organisations to rebuild trust; improving transparency of health data; and increasing independent oversight of the NHS treatment black men receive.
    “For too long, black men have been failed by the very system that is meant to keep us well. The result is a cycle of mistrust, late intervention, and preventable deaths,” he said.
    Read full story
    Source: The Guardian, 24 September 2025
  16. Patient Safety Learning
    “Persistent underfunding” and staff shortages at a teaching trust’s neonatal service is likely to have harmed long-term development of newborn babies, an NHS England review has found.
    A peer review of the service at Leeds Teaching Hospitals Trust, commissioned by NHSE, also found “burnout and moral distress” among its staff, linked to a lack of psychological support for them.
    The review was one of two commissioned by LTHT to look at its neonatal and maternity care, following concerns. HSJ reported in February that MBRRACE-UK, the national mother and baby mortality audit, showed the trust had the highest extended perinatal mortality in the country in 2023, 2022 and 2021.
    A summary of the neonatal review, published in LTHT’s September board papers, said: “This shortfall [in allied health professional staff] not only affects compliance with [National Institute for Health and Care Excellence] guidance for the neonatal follow-up programme but also results in non-compliance with the service specification for inpatient neonatal care.
    “As a result, there is likely to be a negative impact on long-term neurodevelopmental outcomes for patients and reduced support for families.”
    Read full story (paywalled)
    Source: HSJ, 23 September 2025
  17. Patient Safety Learning
    Close to one-third of Oregonians have experience with medical errors like incorrectly prescribed medication or botched surgeries, but providers often failed to adequately inform them of their errors, according to a new report.  
    The Oregon Patient Safety Commission released the findings this week in a 16-page state report on medical harm in the past five years, calling it “the first comprehensive review of post-pandemic patient safety data in Oregon.”
    The Oregon Legislature created the agency in 2003 with the goal of providing an advocate for patient safety while incorporating the perspectives of medical providers, insurers and consumers.
    The survey found that 30% of Oregonians have reported experiencing some form of medical harm in the past few years, whether that involved their own care or “someone close to them.” Medical harm is a broad category that can encompass a wide variety of improper practices or mistakes by doctors and medical providers, which may spiral into further inaccurate treatment plans.
    The findings say that victims want to be informed about errors and receive an apology promptly, but that only about one in three receive such redress. When an error results in what the commission calls “serious health consequences,” researchers found Oregonians were less likely to get an apology.
     “The combination of transparency and apology after medical harm is what patients want and expect,” said TJ Sheehy, director of programs for the Oregon Patient Safety Commission, in a statement. “And while this can be challenging in practice, other studies show that providers do want to disclose when harm has occurred.”
    Read full story
    Source: Oregon Capital Insider, 22 September 2025
  18. Patient Safety Learning
    UK experts have condemned “fearmongering” in the US amid reports surrounding an upcoming announcement from Donald Trump’s administration about a link between paracetamol use in pregnancy and autism.
    Scientists have hit back, with one saying the claim “risks stigmatising families who have autistic children as having brought it on themselves”.
    The Wall Street Journal reported that US health secretary Robert F Kennedy Jr is expected to say Tylenol – which is paracetamol in the UK – is a potential cause of autism.
    In the UK, the NHS website says “paracetamol is the first choice of painkiller if you’re pregnant. It’s commonly taken during pregnancy and does not harm your baby”.
    Dr Monique Botha, associate professor in social and developmental psychology at Durham University, said: “There are many studies which refute a link, but the most important was a Swedish study of 2.4 million births published in 2024 which used actual sibling data and found no relationship between exposure to paracetamol in utero and subsequent autism, ADHD or intellectual disability.
    Dr Botha added: “There is no robust evidence or convincing studies to suggest there is any causal relationship and any conclusions being drawn to the contrary are often motivated, under-evidenced, and unsupported by the most robust methods to answering this question.
    “I am exceptionally confident in saying that no relationship exists.
    “Similarly, pain relief for pregnant women is woefully lacking and paracetamol is a much safer pain relief option during pregnancy than basically any other alternative and we need to take pain seriously for women, including whilst pregnant.
    “The fearmongering will prevent women from accessing the appropriate care during pregnancy.
    “Further, it risks stigmatising families who have autistic children as having brought it on themselves and reinvigorates the long pattern of maternal shame and blame as we’ve seen re-emerge repeatedly over the last 70 years where we try to pay the fault of autism at the mother’s door one way or another.”
    Read full story
    Source: The Independent, 23 September 2025
  19. Patient Safety Learning
    More than 800 patients died while enduring lengthy waits for admission to accident and emergency departments across Scotland last year, with the leading body of emergency medicine professionals warning of a “system in crisis.”
    In what it described as a “national tragedy,” the Royal College of Emergency Medicine (RCEM) said there were an estimated 818 associated excess deaths related to stays of 12 hours or longer before being admitted to A&E departments.
    The death toll - the equivalent of 16 people losing their lives every week - is up by almost a third compared to the 616 estimated deaths in 2023, a trend the RCEM said was “shocking.”
    The new analysis by the college found that a record 76,510 patients waited 12 hours or more to be admitted, discharged, or transferred from A&E last year, some 20,432 higher than the figure in 2023. Of those patients, the majority - some 58,906 - were waiting to be admitted to a ward for further care.
    Dr Fiona Hunter, vice president of RCEM Scotland, said: “The fact that the deaths of more than 800 patients have been lost due to a system in crisis is a national tragedy. Behind this statistic are stories of heartbreak. Because these are people. Mums, dads, brothers, sisters, grandparents - their deaths shattering the lives of families and friends.
    “These are patients who are sick and need further care on a ward. So they are forced to endure extreme wait times for an inpatient bed to become available for them. Often, they will be experiencing this, counting the hours they have been in emergency departments, on a trolley in a corridor, cupboard, or simply any available floor space.”
    Read full story
    Source: The Scotsman, 23 September 2025
  20. Patient Safety Learning
    The NHS is “simply not ready” for a new era of diagnosing and treating Alzheimer’s disease and is not “keeping pace with the science”, experts have warned.
    New drugs and blood tests are set to transform Alzheimer’s care and diagnosis in the coming years, according to a group of 40 expert researchers.
    Researchers also say medications donanemab and lecanemab, which are currently not approved for use by the NHS, slow the progression of Alzheimer’s as effectively as treatments for other conditions such as cancer, rheumatoid arthritis, and multiple sclerosis.
    Writing in a series of papers published in The Lancet, they warn that without rapid reform, the potential of “major innovations” within Alzheimer’s research will not be realised.
    Dr Richard Oakley, associate director of Research and Innovation at Alzheimer’s Society, said the series of papers published in The Lancet “mark the beginning of a new era in Alzheimer’s disease diagnosis and treatment”.
    However, he added, “The painful truth is that the NHS is simply not ready and isn’t keeping pace with the science.
    “We now run the very real risk that people living with dementia will miss out on the opportunity to benefit from these big breakthroughs.
    “It’s vital that the UK government keeps its eye on the ball so people with dementia aren’t left behind. We want to see better access to early diagnosis so people don’t miss out on the narrow window of eligibility to benefit from treatments which can slow Alzheimer’s disease.
    Read full story
    Source: The Independent, 22 September 2025
  21. Patient Safety Learning
    Violence and abuse by patients against staff in GP clinics is widespread globally and usually triggered by long waiting times and the refusal to prescribe requested drugs, research shows.
    The findings are based on a 24-country study of the threats and aggression that family doctors, receptionists and other practice staff experience at work.
    As many as nine out of 10 GP surgery personnel have suffered a physical or verbal assault during their career – in some cases the same proportion reported it over the previous 12 months.
    The threatening behaviour can damage workers’ mental health, increase their stress levels and lead to them wanting to quit.
    The research, by Shihning Chou, an associate professor of forensic psychology at the University of Nottingham, is the first to look at aggression against GP staff as a global phenomenon. She based her findings on an analysis of 50 previous studies from 24 countries, including the UK, China, Australia, Germany, Ireland, Kuwait and Barbados.
    Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners, which represents family doctors in the UK, said: “That incidences of abuse against GPs and our teams are so widespread – and as this research shows, not just in the UK – is extremely distressing. It’s entirely unacceptable for anyone working in general practice to be at the receiving end of abuse of any kind, when they’re just trying to do their jobs.”
    Some assaults are so distressing that GPs call the police or remove perpetrators from their practice list, she added.
    Read full story
    Source: The Guardian, 23 September 2025
  22. Patient Safety Learning
    Patients with a potentially deadly illness will be diagnosed sooner through a new life-saving patient safety initiative called Jess’ Rule that is being rolled out across the NHS in England today.
    Jess’s Rule is named in memory of Jessica Brady, who died of cancer in December 2020 at the age of 27, and will help avoid tragic, preventable deaths as GPs are supported to catch potentially deadly illnesses sooner. 
    In the five months leading up to her death, Jessica had more than twenty appointments with her GP practice but eventually had to seek private healthcare. She was later diagnosed with stage 4 adenocarcinoma. With such an advanced disease there was no available treatment. She was admitted into hospital where she died three weeks later.
    The new initiative will ask GPs to think again if, after three appointments, they have been unable to offer a substantiated diagnosis, or the patient’s symptoms have escalated.
    While many GP practices already use similar approaches in complex cases, Jess’s Rule will make this standard practice across the country, aiming to reduce health inequalities and ensuring everyone – no matter their age or background – receives the same high standard of care.
    Designed in collaboration with the Chair of Royal College of General Practitioners (RCGP) and NHS England, Jess’s Rule will help to catch serious conditions earlier and support GPs with guidelines that bolster their clinical judgment, while encouraging them to reflect, review and rethink if they are uncertain about a patients’ condition.
    Jess’s Rule could support GPs to ensure continuity of care for patients with persistent health concerns. This could involve arranging face-to-face consultations if previous appointments were remote, conducting thorough physical examinations, or ordering additional diagnostic tests.
    It also encourages GPs to review patient records comprehensively, seek second opinions from colleagues, and consider specialist referrals when appropriate.
    Read full story
    Source: Department of Health and Social Care, 23 September 2025
  23. Patient Safety Learning
    The full list of 16 trusts which are retesting tens of thousands of patients who may have been wrongly diagnosed with diabetes can be revealed by HSJ.
    Concerns about over-diagnosis first emerged last year, linked to problems with a device used to monitor glucose levels. But NHS England has so far declined to identify all the trusts involved.
    Now, HSJ  has checked accreditation certifications to confirm which trusts use the Premier Hb9210 HbA1c analyser, manufactured by Trinity Biotech, and can reveal the full list for the first time.
    They include several trusts not previously linked with the issue in public: Calderdale and Huddersfield Foundation Trust; Mid and South Essex FT; Airedale Hospitals; University Hospital Bristol and Weston FT; Stockport FT and Hull University Teaching Hospital Trust.
    They join nine others who are publicly known to have been impacted following HSJ’s coverage last year, or information posted online. These are Norfolk and Norwich University Hospitals FT; South Tees Hospitals FT; York and Scarborough FT; West Hertfordshire Teaching Hospitals Trust; Maidstone and Tunbridge Wells Trust; Barking, Redbridge and Havering University Hospitals Trust; Chesterfield Royal Hospital FT; and County Durham and Darlington FT.
    The Medicines and Healthcare products Regulatory Agency said in a notice in July it had received reports of a positive bias in results which have resulted in patients being incorrectly diagnosed as pre-diabetic. It said the manufacturer would update its instructions to clarify frequency of preventative maintenance required.
    Read full story (paywalled)
    Source: HSJ, 23 September 2025
  24. Patient Safety Learning
    Donald Trump’s administration is on Monday expected to tie pregnant women’s use of the popular medicine Tylenol – known as paracetamol elsewhere in the world – to a risk of autism, contrary to medical guidelines, the Washington Post has reported.
    Trump officials are also expected to announce an effort to explore how the cancer and anemia drug leucovorin could purportedly and potentially treat autism, according to the Post report published Sunday, which cited four sources with knowledge of the plans who spoke on the condition of anonymity because the announcement had not been made.
    Medical guidelines say it is safe for pregnant women to take Tylenol, the over-the-counter pain medication whose active ingredient is known as acetaminophen in the US and paracetamol elsewhere in the world. But, as the Post noted, federal health officials have been reviewing previous research – including an August review by researchers from Harvard University and Mount Sinai hospital – that suggested a possible link between Tylenol use early in pregnancy and an increased risk of autism in children.
    Earlier in September, the Wall Street Journal reported that Trump’s health secretary Robert F Kennedy Jr planned to announce that use of Tylenol by pregnant women was potentially linked to autism, which is defined as a neurodevelopmental condition marked by social as well as communication difficulties and behaviors that are repetitive.
    As the Post reported, some medical trials involving administering leucovorin to children with autism have shown “what some scientists describe as remarkable improvements in their ability to speak and understand others” – though those trials are considered early.
    Kennedy has claimed that the US is in the grip of an “autism epidemic” fuelled by “environmental toxins”.
    Read full story
    Source: The Guardian, 21 September 2025
  25. Patient Safety Learning
    “Racism and marginalisation” at Nottingham University Hospitals Trust meant families “felt pushed out” and resulted in “tragic outcomes”, according to the chair of the inquiry into its maternity services. 
    Senior midwife Donna Ockenden told HSJ’s Patient Safety Congress that talking to the hospitals’ “wider community” found “significant evidence of racism, marginalisation… ignoring, turning the backs on” people.
    “A whole community felt pushed out in the cold,” she said, and families had been confronting a “brick wall” when dealing with the maternity unit.
    They met an attitude from staff that “you are not coming in here, we are not listening to you, you can’t be in labour, we know what we are doing, and you don’t,” Ms Ockenden said. “There were a number of really tragic outcomes, with babies being born in the wrong place without the correct equipment.”
    Some 2,460 families’ cases are now formally included in the review, and there were a further 520 which could be learned from, she said. There are 850 current and former staff engaged, and Ms Ockenden said she was working closely with current trust leadership. She said several senior doctors had told her team they had raised safety issues at earlier stages.
    Read full story (paywalled)
    Source: HSJ, 22 September 2025

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